Progress in Treating Depression and Diabetes

"Depression makes everything more difficult," says Scott Strange, 49, of Kansas City, who was diagnosed with type 1 diabetes in 1970 and has struggled with depression since childhood. "I ignored my diabetes for four decades." Though he took insulin, he avoided carb counting, blood glucose measurements, and all the other daily practices that help keep people with type 1 healthy.

No one says living with diabetes is easy, but adding depression to the mix can turn taking care of yourself into an overwhelming burden. Depression is common, too, affecting 1 in 6 Americans, and some studies suggest the rates are higher in people with diabetes. There is a silver lining, though. New approaches that treat diabetes and depression give hope that these dual burdens can be lifted.

Not Happy TogetherPeople with type 2 diabetes are at a 54 percent greater risk of developing depression than those without type 2, according to a 2008 study in the Journal of the American Medical Association. The study also found a modest association between depressive symptoms and the development of type 2. "It's clear that depression is a risk factor for diabetes, and there is evidence that it goes in both directions," says Jeffrey Gonzalez, PhD, assistant professor in the Diabetes Research Center at the Albert Einstein College of Medicine. "It's difficult to say which comes first. It's a 'chicken or egg' problem." The link between type 1 diabetes and depression is even less clear, as few studies have focused on this question.

Researchers are exploring both biological and behavioral underpinnings to explain the relationship between diabetes and depression. On the biological side, depression is linked with changes in hormone levels, the nervous system, and the brain that may increase blood glucose levels. These biological changes could potentially trigger diabetes or worsen blood glucose control in those with the condition.

On the behavioral side, depression makes it difficult for people with diabetes to follow diet and exercise recommendations, says Hillary Bogner, MD, MSCE, assistant professor of family medicine and community health at the University of Pennsylvania. Depressed people are less likely to take care of themselves, says Bogner, perhaps forgoing medication, exercise, and blood glucose checks. Overeating may be used to soothe an aching mind, at least temporarily, but may also promote weight gain.

Depression Signs and Symptoms

The number, severity, frequency, and duration of the following signs and symptoms of clinical depression vary from person to person, but the illness is defined as a condition that affects daily life.

Persistent sad, anxious, or "empty" feelingsFeelings of hopelessness or pessimismFeelings of guilt, worthlessness, or helplessnessIrritability, restlessnessLoss of interest in activities or hobbies that once were pleasurable, including sexFatigue and decreased energyDifficulty concentrating, remembering details, and making decisionsInsomnia, early-morning wakefulness, or excessive sleepingOvereating or appetite lossThoughts of suicide; suicide attemptsAches or pains, headaches, cramps, or digestive problems that do not ease even with treatmentSource: National Institute of Mental Health

Defining DepressionStudying depression and diabetes is a challenge, according to Gonzalez, because there is disagreement over whether depression studies measure "true depression." To detect depression, researchers typically ask study participants a variety of questions, such as "Do you feel like a failure?" If you score high enough on such a test, you're labeled as depressed. Gonzalez calls these tests "a crude measure" and says they are meant not to diagnose clinical depression but to identify those at risk. "They are trying to cast a wide net to catch everyone," he says. In clinical practice, people who show depressive symptoms in screening tests are further evaluated to determine whether they are actually depressed.

The result, he contends, is that studies may be counting too many people with diabetes as clinically depressed. A 2007 study published in Diabetes Care found 22 percent of people with diabetes had screening scores that indicated depression. Further evaluation found that 70 percent of these people were not clinically depressed and that 34 percent of people who tested negative for depression were clinically depressed. Gonzalez suspects that in people with diabetes, the tests may be picking up "diabetes-related distress" rather than clinical depression. "Emotional distress may be part of diabetes, not a separate issue," he says. "Maybe when we think we are seeing depression, we are seeing this other thing." Distress is defined as a temporary anxiety or mental strain brought on by external factors. When associated with a chronic disease, distress may linger but remains distinct from depression, which is a mental illness. There are effective ways of alleviating distress, Gonzalez says, such as mindfulness training and problem solving that may offer relief.

Double TroubleRegardless of whether these tests measure true depression or diabetes-related distress, their results are still important regarding the health of people with diabetes. The 2007 study clearly showed that people who tested positive for depression had higher blood glucose levels and got less exercise. A 2010 study in Diabetes Care found that major depression increased the risk of diabetic nerve, kidney, or eye disease by 36 percent and raised the risk of a heart attack or stroke by 24 percent.

So does treating depression improve diabetes? Unfortunately, this has not been consistently supported by research, says Gonzalez. A 2006 study in Annals of Family Medicine found that after a group of depressed people with type 2 diabetes spent a year in an enhanced depression treatment program, which included both medication and counseling, their diabetes self-management did not get better. "I want to believe that treating psychological issues can improve health outcomes, but I think that may be too much to expect from psychotherapy," says Gonzalez.

All is not lost, though. The key to better health, according to Bogner, may be an integrated approach. "If someone's depression isn't controlled, you won't be able to control their diabetes very easily," Bogner says, so you have to tackle both conditions at the same time. She worked on a study published this year in Annals of Family Medicine that tested a program that integrates the treatment of diabetes and depression. Each patient who received integrated care had a care manager who kept in touch with all of the participant's health care providers, including primary care physicians, diabetes educators, and psychiatrists. Three months into the study, 61 percent of patients receiving integrated care reached an A1C of less than 7 percent, compared with just 36 percent of a group receiving standard treatment. Plus, 59 percent of people in the integrated program ceased to have depression, compared with 31 percent in the usual care group.

If you're concerned about depression, Bogner recommends talking to your primary care physician. "There are medical reasons for people to have symptoms of depression," she notes. "We want to make sure people don't have thyroid disease," or another illness with symptoms similar to those of depression. From there, the treatment path depends on the person. Many cases of depression can be treated by a primary care physician, who can prescribe antidepressants if necessary. Some antidepressants cause weight gain, and not all are suitable for people with diabetes, so talk to your doctor about side effects. In some cases, a doctor may refer a patient to a mental health specialist, such as a psychiatrist or psychologist, depending on the severity of depression and patient preferences. "With depression treatment," says Bogner, "we just have to try to find something that works."

Scott Strange has stopped ignoring his diabetes. "I'm taking much better care of it now," he says. Over the years, he's tried a variety of medications for depression, with varying success, and a year ago he started talk therapy, which he's found challenging yet helpful. But he says the big change that prompted him to take on his diabetes happened when he found an online diabetes community. "For years I thought I was alone," he says, but he now is active as a blogger and on Twitter, learning from and socializing with others facing similar challenges. "If I had practical advice for anybody, it's to know you're not alone."